SELECTED READINGS

IN

ORAL AND

MAXILLOFACIAL SURGERY

STANDARDIZED DIGITAL
PHOTOGRAPHY FOR
VIRTUAL ORTHOGNATHIC
SURGICAL ­PLANNING

Octavio Cintra, DDS

Christian Coachman, DDS, CDT
Luiz Carlos Da Silva, DDS, MSC, PHD
Thiago Santos, DDS, MSC

Volume 20, Number 3 October, 2012

 STANDARDIZED DIGITAL PHOTOGRAPHY FOR VIRTUAL
ORTHOGNATHIC SURGICAL PLANNING

Octavio Cintra, DDS, Christian Coachman, DDS, CDT,

Luiz Carlos Da Silva, DDs, Msc, PhD, Thiago Santos, DDS, Msc

HISTORY OF ORTHOGNATHIC SURGERY

The historical development of orthognathic surgery has not been uniform and continuous, but
instead followed a rather intermittent course. The early-phase was mainly limited to the mandible
while maxillary surgical procedures came later. The first operation for the correction of malocclu-
sion was Hullihen’s procedures in 1849. The cradle of early orthognathic surgery, however, was in
St. Louis where the orthodontist Edward Angle (1898) and the surgeon Vilary Blair (1906) worked
together. They carried out the first described ostectomy of the horizontal ramus for the correction
of a case of mandibular prognathism. Blair was also the pioneer who stressed the importance of
orthodontics in dentofacial discrepancy treatment.1
Technology has been evolving over and be ­responsible throughout the evalu-
time, and optimizing it is a key factor for ation process, and there should be always
obtaining predictable results. Precision is a joint discussion ­between the surgeon, the
­required from the first analysis of the patient orthodontist and the patient, before a defini-
to be incorporated into treatment planning. tive treatment plan is made. Full history such
as medical and dental history should be ob-
In this review, we describe a photo- tained before the examination. Articulated
graphic protocol based on the principles of dental models should be prepared for later
reliability and consistency in the photographs evaluation. Understanding of the patient’s so-
taken. A special technique, called Digital cio-psychological profile will greatly reduce
Smile Design (DSD) is used for facial analy-
2
misunderstandings by knowing the patient’s
sis, and it can make possible any other ­related motives for surgery and expectations.
intraoral or facial correlation or analysis
(Figs. 1-3 on page 2). The differential diagnosis process
generates a problem list and treatment plan-
Planning in orthognathic ning options to discuss with the patient. The
surgery selection of the appropriate procedure must
be based on the clinician’s anticipated objec-
tives with regard to esthetics, function, and
An accurate diagnosis will lead
stability,3,4 but also on the patient’s objectives,
to good surgical planning, thus favorable
expectations, and perceived needs.5 Impor-
­results. A systematic and full evaluation of
tant factors in the selection of orthognathic
the patient is of utmost importance. The or-
surgical procedures and treatment planning
thodontist and the surgeon should take part
are the stability of the results, the predictabil-

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Standardized Digital Photography Octavio Cintra, DDS; et al.

Figure 1. Frontal digital photograph with vertical and

horizontal planes.
____________________________________

ity of hard and soft tissue changes to achieve B

facial balance and the patient’s response.6

The analysis of soft tissue, along-

side the study models and cephalometry, has
­become essential for the diagnosis of dento-
facial deformities, because a treatment based
only in cephalometrics can create undesir-
able results. Arnett and Bergman7,8 presented
“­Facial keys to orthodontic and treatment
planning.” They used a three-dimensional
clinical analysis of the face both in orthodon-
C
tic diagnosis and in the planning of surgical
cases.
Figure 2. A. Digital Smile Design in the oral area
To perform soft tissue cephalometric followed by B. and C. casts planning the ideal smile
analysis, the patient should be examined clin- ­design.
ically in natural head position (NHP), with
the articular condyles seated in the fossa and

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Standardized Digital Photography Octavio Cintra, DDS; et al.

Cephalometric prediction in orthog-

nathic surgery can be performed manually or
by computer, using several currently avail-
able software programs, alone or in combina-
A tion with video images. The manual methods
of cephalometric prediction of the orthogna-
thic outcome are time consuming, whereas,
computerized methods facilitate and speed
the visualized treatment objective. Both man-
B ual and computerized cephalometric predic-
tion methods are two-dimensional and will
Figure 3. Composite reconstruction of the upper arch
always have limitations, because they are
A. after Digital Smile Design treatment planning and
B. prior to the jaw surgery. based on correlations between single cepha-
____________________________________ lometric variables and cannot fully describe a
three-dimensional biological phenomenon.6
the lips relaxed. This posture is imperative
for reliability and standardization of cepha-
Two basic problems are associated with
lometric analysis. Cephalometric analysis
traditional 2-dimensional cephalometry First,
cannot be used without facial analysis to
many important parameters cannot be mea-
complement and elucidate the cephalometric
sured on plain cephalograms, and second,
data. The analysis should emphasize midface
most 2-D cephalometric measurements are
facial structures not shown in a convention-
distorted in the presence of facial asymme-
al cephalometric analysis, for example, the
try. Three-dimensional (3-D) cephalometry,
­infraorbital rim and contour of the alar base,
which has been facilitated by the introduction
which are important indicators of the antero-
of cone-beam computed tomography scans,
posterior position of the maxilla.9
can solve these problems, but only if the un-
reliability of internal reference systems and
Surgery of the models is an impor-
some 3-D measurements, along with the lack
tant step in orthognathic surgery planning,
of tools to assess and measure symmetry, are
being essential to the success of surgical
resolved.12
procedures. Eliminating some stages of the
treatment planning (e.g., facial analysis, pre-
­Despite the promising capabilities
dictive tracing or model block surgery) has
of 3-D the technology is not yet reliable for
been presented in the literature, but doing so
­orthognathic prediction.6 However, the dif-
introduces great risk of inaccuracy that could
ferent methods of prediction are useful tools
induce undesirable changes after surgery.10
for orthognathic surgery planning and facili-
Errors in model surgery performed with an
tate patient communication. We propose in
articulator have also been reported as a pos-
this review the use of 2-D photographs for
sible cause for discrepancies related to seg-
obtaining a 3-D analysis of the patient in pre-
ment positioning.11
sentation software.

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Standardized Digital Photography
Importance of the Accuracy of the Data
Collection
Elective operations are increasingly
being done to correct skeletal discrepan-
cies and severe malocclusion. This may
be the result of a wider range of operations
­being available for treatment of complex
dysgnathia, and older subjects being able to
withstand such operations.13 These develop-
ments have resulted in the need for a method
that will rapidly and accurately predict the
outcome of combined orthognathic and sur-
gical treatment. The digitization of cephalo-
grams have made their analysis much faster
and easier, and the use of software for plan-
ning orthognathic operations is popular.14
Many studies of stability after orthog-
nathic correction of dentofacial deformities
have been published,15 but only a few have
attempted to evaluate orthognathic precision
by comparing preoperative prediction with
postoperative outcome.13 For prediction of
the results of orthognathic operations, plan-
ning devices usually involve clinical evalu-
ation, photographs, and freehand surgical
simulation based on cephalometric tracings
and study model operations.16 To evaluate the
position of the maxilla and mandibula post-
operatively, cephalometric analysis of the
surgical result immediately after removing
the intermaxillary splint should be consid-
ered.12,16
New methods of planning treatment
have enabled correction of virtually any
type of dentofacial deformity, but problems
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Octavio Cintra, DDS; et al.
remain. As with all manual cephalometric
tracing, digitization is prone to errors, includ-
ing incorrect identification of landmarks and
angles and errors in transfering of predicted
data from digitized cephalograms to the study
model operation and intraoperative sites.17 If
greater shifts in the transversal dimension are
necessary, exact planning should be adapted
with three-dimensional planning devices to
avoid significant differences.18
Importance of the Accuracy of the
Photographs
Complex clinical appearances of
p­ atients in craniomaxillo-facial surgery and
facial plastic surgery are usually difficult to
describe in words. Therefore, much of our
professional time is spent in judging and dis-
cussing pictures and photographs. For that
purpose standardized views and high-quality
photographs are fundamental for pre- and
postoperative documentation.
Clinical photographs are most ­commonly
used to assist accurate planning of a surgical
procedure and to illustrate the purpose of the
surgical intervention for the patient. Consis-
tent documentation of clinical diagnosis and
treatment is also demanded in medico-­legal
cases. In addition, photo-documentation with
reliable pre- and postoperative pictures are
invaluable for scientific development, surgi-
cal education and staff training.19 Some au-
thors recommend that high-quality clinical
photographs become an integral part of the
patient’s record, complimenting radiographs
and other medical images.20
5 VOLUME 20.3
Standardized Digital Photography
Clinical photographs taken before,
during and after orthodontic treatment form
an essential part of the patient’s records.
If correctly taken, they offer more use-
ful ­information about the malocclusion and
treatment than any other clinical record.
There are, however, many potential sources
of ­errors in obtaining these records. Photo-
graphs of inadequate quality may misrepre-
sent the patients starting malocclusion, may
inaccurately ­reflect progress with treatment
or may inaccurately record dental anomalies
and defects that may be present.
With both conventional and digital sys-
tems, errors related to use of mirrors and
­retractors and patient positioning are com-
mon. With digital equipment a whole new
range of possible errors has been introduced
and specific problems related to the digital
system have been discussed in detail.21 Thus,
we highlight below a clinical protocol for
photographs in order to minimize errors to
achieve the highest possible quality of pho-
tographic records.
PHOTOGRAPHS AND FACIAL
ANALYSIS
In orthognathic surgery, both the
a­cquisitions of a harmonious profile and an
­improvement in occlusal function are impor-
tant goals. Therefore, an objective and quan-
titative analysis of facial morphology before
and after surgery is essential,22 and it can
be obtained by different methods. One such
method is digital photography, which has
the advantage of not exposing the patient to
­potentially harmful radiation while still pro-
viding a good assessment of the harmony and
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Octavio Cintra, DDS; et al.
esthetics of external facial structures, includ-
ing the influence of soft tissues.
Facial analysis is used as a diagnostic
tool in orthodontics and orthognathic surgery
to assist in directing treatment and to meet
one of the patient’s main motivations: facial
aesthetics. Once these techniques are stan-
dardized, photographic analysis can be a use-
ful complement to conventional ­radiographic
and cephalometric analysis because ortho-
dontics and orthognathic surgery ­require
­numerical data to understand the concept of
beauty.
To obtain consistent esthetic outcomes,
the gathering of diagnostic data from ques-
tionnaires and checklists is important.23 How-
ever, as in restorative dentistry, much of this
information may be lost if it is not transferred
adequately to the facial analysis.24 The diag-
nostic data should guide the subsequent treat-
ment phases, integrating all of the patient’s
needs and desires, as well as the patient’s
functional and biologic issues.2
The DSD is a multi-use conceptual
tool that can reinforce diagnostic vision,
­increase communication, and enhance pre-
dictability throughout treatment. The DSD
permits careful analysis of the patient’s facial
and dental characteristics along with any crit-
ical factors that may have been overlooked
during clinical, photographic, or diagnos-
tic cast-based evaluation procedures. The
­illustration of reference lines and shapes over
extra- and intraoral digital photographs in a
predetermined sequence can widen diagnos-
tic visualization and help the restorative team
evaluate the limitations and risk factors of a
given case, including asymmetries, dishar-
6 VOLUME 20.3
Standardized Digital Photography
monies, and violations of esthetic principles.2
DSD sketches can be performed in presen-
tation software such as Keynote™ (iWork,
Apple, Cupertino, California, USA) or Mi-
crosoft PowerPoint™ (Microsoft Office, Mi-
crosoft, Redmond, Washington, USA). This
improved visualization makes analysis of the
patient easier.
The DSD protocol is characterized by
­effective communication within the interdis-
ciplinary team. Team members can identify
and highlight discrepancies in soft or hard tis-
sue morphology and discuss the best available
solutions using the amplified ­images. Each
professional can add information ­directly
onto the slides in writing or ­using voice-over,
thus simplifying the process even more. All
team members can access this ­material when-
ever necessary to analyze, ­alter, or add ele-
ments during the diagnostic and management
phases.
The implementation of the DSD proto-
col can make diagnosis more effective and
______________________________________________________________________________
Figure 4. Suggested photographic layout for the Digital Smile Design protocol.
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Octavio Cintra, DDS; et al.
treatment planning more reliable. The efforts
required to implement DSD are rewarded by
more logical and straightforward treatment
sequencing, leading to savings in time, mate-
rials and cost during treatment.
Digital Smile Design
According to Coachman and Calam-
ita,2 the DSD protocol offers advantages in
the following areas: 1) Esthetic diagnosis,
2) Communication, 3) Feedback, 4) Patient
management, and 5) Education.
Esthetic diagnosis
When the professional first evaluates
a new patient with esthetic concerns, many
critical factors could be overlooked. A digital
photographic and analysis protocol enables
the dentist to visualize and analyze issues that
he or she may not notice clinically. Drawing
of reference lines and shapes over extra- and
intraoral digital photographs can easily be
performed using presentation software
7 VOLUME 20.3
Standardized Digital Photography Octavio Cintra, DDS; et al.

Table 1: technical guidelines for high quality

digital photographs.
Nikon D90/D200/D300/D7000 Approximate References
Face with Smile & Intraoral Smile & Intraoral XR Photography
bouncers with bouncers without bouncers
ISO 400 200 200
Flash Power 1/1 1/1 1/8
“f” around 13 22 22
Focus auto Manual Manual
Speed 125 125 125
Flash Control Manual Manual Manual
Image Quality JPEG Fine JPEG Fine JPEG Fine
White Balance Kelvin “K” 5560 Kelvin “K” 5560 Kelvin “K” 5560
Image Size Large “L” Large “L” Large “L”
Camera Mode Aperture mode Aperture mode Aperture mode Auto
“m” “m” “m”
Color Space /RGB /RGB /RGB
______________________________________________________________________________

DIGITAL PHOTOGRAPHIC
PROTOCOL

Equipment Needed

The protocol requires a digital single-

lens reflex camera (DSLR) body. For exam-
ple, our protocol employs a Nikon D7000®
(Nikon, Melville, New York, USA). A macro Figure 5. Facial digi-
lens (105 mm) is also necessary, and arms tal photographs. The
for wireless flashes associated with bouncers black background helps
are employed. Figure 4 illustrates the photo- ­define the patient’s fea-
graphic layout. tures, and the presence
of a mirror helps main-
tain natural head posi-
Technical Guideline tion.

To standardize the photographic pro-

cedure and obtain high quality photographs,
a guideline is followed. The values and types
of ISO, flash power, lens aperture (“f”),

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Standardized Digital Photography Octavio Cintra, DDS; et al.

f­ ocus, speed, flash control, image quality,

white balance, image size, camera mode and
color space for different photographs with or
without bouncer are summarized in Table 1
(On page 7).

Patient’s and Professional Positions

A

Face

Use a black background behind the

­patient’s head and a mirror to help main-
tain Natural Head Position. Additionally, the
camera must be in the same position, with
B the equipment stabilized vertically (Fig. 5 on
page 7).
Figure 6. A. The angle of the camera and the black
background behind the upper arch produce the view in
B. of the smile line and gingival margin levels.

______________________________________________________________________________

A B C

Figure 7. Frontal facial photographs. A. At rest; B. Smiling; C. Open smile with teeth apart.

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Standardized Digital Photography
A B
C D
Figure 8. 3/4 facial photogrpahs. A. Right side at
rest. B. Left side at rest; C. Right side when smiling,
D. Left side when smiling. All photographbs were
taken at 45 degrees.
____________________________________
A B
Figure 9. Lateral facial photographs. A. Profile smile;
B. Profile rest.
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Octavio Cintra, DDS; et al.
Intraoral
Use a black background behind the
­upper arch to display the smile line and the
levels of the gingival margin. Additionally,
the camera must be in an approximate angle
of 45º with the maxilla (Fig. 6, facing page).
___________________________________
Figure 10. 12 O’clock special photograph.
___________________________________
Type of Photographs
Face
Three photographs for frontal facial
analysis are taken: at rest, while smiling and
during an open smile with teeth apart (Fig. 7,
facing page). Four 3/4 facial photographs (at
45º) are taken at rest and while smiling (Fig. 8).
Two photographs in profile are taken at rest
and while smiling (Fig. 9).
A special 12 O’clock photograph is
taken with the patient in supine position and
the camera lens aligned to make a straight
line with the nasal apex, to obtain a photo-
graph of the relationship of the teeth and lips
while smiling (Fig. 10).
Three photographs for frontal intra-
oral analysis are taken: with the teeth apart,
in maximum intercuspation (MIC) and dur-
ing protrusion (Fig. 11 on page 10). Images
of the teeth apart and in protrusion allow
10 VOLUME 20.3
Standardized Digital Photography Octavio Cintra, DDS; et al.

A B C
Figure 11. Intraoral frontal photographs. A. Teeth apart, B. Maximum intercuspation; C. Protrusion. Teeth apart and
protrusion allow analysis of the plane of occlusion.
______________________________________________________________________________
analysis of the occlusion plane. Two occlusal
photographs are taken of the upper jaw and
lower jaw (Fig. 12).
A B
Figure 12. Intraoral occlsual photographs. A. Upper
oclussal; B. Lower occlusal.

______________________________________________________________________________

Figure 13. Clinical Case 1: Full face protocol for facial treatment planning.

Figure 14. Clincial Case 1: Informal facial photographs.

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Standardized Digital Photography Octavio Cintra, DDS; et al.

Figure 15.Clinical Case 1: Close-up photographs for smile and tooth-lip relations analysis.

Figure 16. Clinical Case 1: Intraoral photographs.

Figure 17. Clinical Case 1: Special intraoral photographs.

______________________________________________________________________________
DEMONSTRATION OF CLINICAL Furthermore, full-face informal photographs
CASES are ­employed to permit a less structured and
natural analysis (Fig. 14, facing page). Close-
up photographs allow analysis of the smile
The first clinical case demonstrates
and tooth-lip relations (Fig. 15). Intraoral and
full face photographs taken for facial treat-
special intraoral photographs are shown in
ment planning. It is worth noting that this
figures 16 and 17, respectively.
protocol gives the sensation of tri-dimen-
sionality (3-D) even when using two-dimen-
The second clinical case reinforces
sional photographs (Fig. 13, facing page).
the indication of DSD for a standardized

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Standardized Digital Photography Octavio Cintra, DDS; et al.

analysis of patients undergoing orthogna-

thic surgery. Figure 18A illustrates the DSD
analysis in a frontal facial photograph; figure
18B shows the DSD during smiling. Figure 19
displays the full face photographs at rest and
A B during smiling, ­respectively. Figure 20 (on
page 13) combines three facial photographs:
3/4 at rest and frontal during smiling. Figure
Figure 18. Clinical Case 2: Standardized facial photo- 21 (on page 13) shows the final occlusion at
graphs with vertical and horizontal planes. A At rest;
maximum intercuspation in frontal, right and
B. While smiliing.
______________________________________________________________________________

Figure 19. Clinical Case 2: Suggested facial layout. A. with profiles at rest; B. With profiles while smiling.

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Standardized Digital Photography
Figure 20. Clinical Case 2: Facial 3/4 views with frontal smile with teeth apart (center), that shows better facial contour.
Figure 21.Clinical Case 2: Intraoral regular photographs of final occlusion at maximum intercuspation.
Figure 22. Clinical Case 2: Frontal facial photograph
during smiling, with relationship of maxillary and
mandibular central incisors (insert).
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Octavio Cintra, DDS; et al.
____________________________________
left occlusion views, which is the most com-
mom protocol for the evaluation of the occlu-
sion and intercuspation. Figure 22 displays
a frontal facial photograph during smiling
associated with the final occlusion to dem-
onstrate the relation of the maxillary central
incisors and the mandibular central incisors
(i.e., overjet and overbite).
The final two cases demonstrate the
standardization of the present protocol, with
the photographs being practically identical.
Figures 23 and 24 (on page 14) give the sen-
sation of tri-dimensionality in the facial and
intraoral photographs, respectively. The case
illustrated by Figures 25-27(on pages 14 & 15)
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Standardized Digital Photography Octavio Cintra, DDS; et al.

Figure 23. Clinical Case 3: Facial layout giving the sensation of tri-dimensionality.

Figure 24. Clinical Case 3: Preoperative (top row) and postoperative (bottom row) intraoral photographs.

Figure 25. Clinical Case 4: Facial layout giving the sensation of tri-dimensionality.

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Standardized Digital Photography Octavio Cintra, DDS; et al.

Figure 26. Clinical Case 4: Facial smile layout.

Figure 27. Clinical Case 4: Preoperative (upper row) and postoperative (lower row) intraoral photographs.

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Standardized Digital Photography Octavio Cintra, DDS; et al.

includes frontal facial analysis and intraoral
analysis. Note that this protocol allows a bet-
ter juxtaposition of preoperative and postop-
erative intraoral photographs, making differ-
entiation easier for professionals and patients.
CONCLUSION
The DSD protocol enables the oral and
maxillofacial surgeon to work together with
orthodontists and other dental professionals
in a practical and reliable way of communi-
cation. Moreover, a digital photographic and
analysis protocol using presentation software
permits visualization and analysis of issues
that might not be noticed clinically without
the additional cost of a special software anal-
ysis prior to orthognathic surgery.
___________________________________
Dr. Octavio Cintra received his D.D.S.
from the University of Campinas (UNI-
CAMP), his oral and maxillofacial training
was obtained at The University and Hospital
of Santa Casa de Misericordia de Sao Paulo,
his fellowship was at Southwestern Medical
Center at Dallas in the Division of Oral and
Maxillofacial Surgery, Parkland Memorial
Hospital, Dallas, Texas, USA. He maintains a
private practice strictly focused on orthogna-
thic surgery in Sao Paulo/SP, Brazil.
also became an instructor. Currently he is the
scientific coordinator of the e-learning web-
site www.identalclub.com. He has lectured
and published internationally in the fields of
­esthetic dentistry, dental photography, oral
­rehabilitation, dental ceramics and implants.
Dr. Luiz Carlos Da Silva received his
D.D.S. from The Dental School of The Fed-
eral University of Sergipe, his PhD degree
from the Dental School of The University of
Pernambuco, and his oral and maxillofacial
training from the Umberto Io Hospital. Cur-
rently, he is Adjunct Professor in the Depart-
ment of OMS at The Federal University of
Sergipe. He also maintains a private practice
in Aracaju. His PhD thesis concerned bone
repair and he has written 40 articles and 5
book chapters on OMS.
Dr. Thiago Santos received his D.D.S.
from the Federal University of Sergipe and
his Msc. degree and oral and maxillofacial
surgery training from the University of Per-
nambuco. Currently, he is PhD Student in the
Department of OMS at the University of São
Paulo.

Dr. Christian Coachman graduated

in Dental Technology in 1995 and in Den-
tistry at the University of São Paulo/Brazil
in 2002. He is a member of the Brazilian
Academy and Society of Esthetic Dentistry
and of the American Academy of Esthetic
Dentistry (AAED). Moreover, Dr. Coachman
­attended the Ceramic Specialization Program
at the Ceramoart Training Centre, where he

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Standardized Digital Photography
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17. Schneider M, Tzscharnke O, Pilling E, Lau- 1RELATED ARTICLES IN SELECTED

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READINGS IN ORAL AND MAXILLO-
FACIAL SURGERY
Digital Photography for the Oral and Maxillofa-
cial Surgeon. Waldemar D. Polido, DDS,
MS, PhD; Daniel Mazzoleni, DDS; An-
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